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#1 of 26 Old 02-08-2002, 05:11 AM - Thread Starter
 
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Hi - I'm new here & I have a question - if anyone knows anything that might help, please let me know -
I live in NY State. My dd was born at home 2 years ago and at the time I was on straight medicaid, which paid my midwife. Now I'm pg again, due in March and have been seeing the same midwife but I was put on a 'managed care' program (HMO) by medicaid (I had no choice - everyone was). The problem is, my midwife isn't on the HMO's list of care providers and neither is the only other midwife in the area that attends homebirths. I spoke to the woman in charge of making these decisions at the HMO and was told "You'll have to have a hospital birth like everyone else". I might be wrong, but isn't there some kind of law on my side here? Does anyone know or have a link to a website that might help? Thanks.
Erika
dd Tara 4/19/00
EDD 3/24/02
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#2 of 26 Old 02-09-2002, 12:03 AM
 
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I have the same HMO dilemma. I have private HMO insurance, and they won't pay for anyone who is not a "preferred provider." They won't even pay for lab tests, us's , etc, if it is not ordered by a dr. on their list. A midwife I spoke to said that HMO's can get away with this simply because they are not saying they won't pay for midwives- they just won't pay for anyone that they do not contract with and put on their provider list. The doctors on the provider list agree to bill services at a lower than normal rate for HMO members- in return, the HMO will give the Dr.s a certain amount of money each month for those members, regardless of whether or not they visit the Dr. ( i know this since I work at a HMO medical clinic.) If you have a PPO provider that allows you to see any Dr, then you can force them to pay for a portion of a homebirth. this is all in CA, so I imagine NY could be different. I have no idea if Medicaid would make a difference. HMOs suck!!
I hate to have the cost keep me from considering a homebirth. Midwives out here generally aren't cheap, plus any lab tests are additional to their fees. I was thinking of seeing an HMO ob for the initial labs, then transferring to a midwife. I'm not sure. Good luck to you, and if you find any info, let me know!!!
I'd love to find a loophole, but doubt if I will.
Take care, Becky
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#3 of 26 Old 02-09-2002, 12:27 AM
 
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It may be worth it to look into a very affordable payment plan and hire a homebirth midwife yourself. The women around here who use my midwife pay out of pocket, because we don't feel our rights should be governed by HMOs and OBs. It's $1700, and it includes in-home prenatals, labor, birth, and postpartum care. Some of her clients are still paying her back - and their "babies" are in the third grade!! Ask around; ask your homebirth midwife if she's willing to do this, or if she's too pricey, ask her to recommend a CPM or experienced lay midwife. It's worth a try for an ideal birth experience!
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#4 of 26 Old 02-17-2002, 04:11 AM
 
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I have made it my mission to get Blue sheild HMO to pay for a homebirth!!!! I' m in California too, I am 100% serious about it and I am keeping a phone log with names dates and times that I talk to people about it. I am quoting their evidence of coverage book to back up what I want. I have run into some really confused people. You just have to keep calling till you find someone that has authority.

The most promising thing I have so far came from rae anino at blue sheild hmo's customer service # x5330
She told me that in effect yes they are limiting my choice of care and that midwifery is a legal safe alternative and that I should have my primary care physician submit a request to the IPA for plan approval and coverage of my CNM. She then told me other out of IPA ( independent physician association) providers have been approved in the past.

If I fail, I will be going thru the review and grievance process and the process they describe to institute change in the hmo. It is my view that they have to get requests for this so they see that members want this and then they will clue in that it is cheaper.


Or I could switch to the blue sheild PPO and pay 20% (the copay on the ppo) of the midwife. The ppo evidence of coverage book plainly states that they do cover CNM 's !!!
The worst I can see happening is being in the hmo with a doc for the first 6 mo then switching to the ppo midwife and paying the 20% out of pocket for the delivery and last few mo.s care.

I talked to the billing lady for the midwife and she said that it looks like one of their other patients will be reimbursed by her hmo ( not blue sheild) for the whole thing, though she had to pay it up front.
I REFUSE TO GIVE UP!!!
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#5 of 26 Old 02-17-2002, 08:47 AM
 
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A few thing you might want to check into...with some HMOs, if you step out of their list of providers they will still pay a PORTION of your medical bill. Also, does your midwife have a physician as a backup? If that dr. is in the HMO plan, perhaps he can sign off on the insurance. You might also inquire if prenatal care is covered differently than the actual delivery. One midwife I know bills separately for each as some companies will cover the prenatal but not the actual homebirth. Good luck.

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#6 of 26 Old 02-18-2002, 08:46 PM
 
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I live in Louisiana and have PPO Plus. I am wanting a homebirth for my next baby (not preg yet, but working on it). Are any of you from Louisiana or have this insurance? I'm wondering if our insurance will even pay for a homebirth or a mid-wife. There are none listed in my book. I don't want to go back to a hospital again. I've already had three boys without the use of drugs and each time they confined me to my bed and wouldn't let any of my older children attend the birth. We are a close knit family and they have seen the birthing tapes and know what to expect and have seen me in hard labor after the hospital sent me home "to dialate. " They didn't even want me at the hospital until either my water broke or I was 6 cm. I just can't go through that again! The only reason I went back this last time after dialating was because I tested positive for GBS. Help me if you can! Thanks all!:
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#7 of 26 Old 02-19-2002, 07:16 PM
 
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Tinyone,
What department do you go to first at the HMO? I have Pacificare and don't even know how to begin questioning them. They just keep telling me that if it's not a listed provider, no coverage. Period. If you find any loopholes I could use, PLEASE let me know, I would really appreciate it. We are considering switching to PPO for the year that I'm pregnant (not yet)
Insurance here in CA is so damn expensive for the lousy covwerage that you get, it's really pitiful.
Sometimes I feel like I'd rather just pay the midwife than to go through all the hassle trying to get insurance to do anything. I don't have enough time!!!!
Thanks! Becky
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#8 of 26 Old 02-19-2002, 08:18 PM
 
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You must get a copy of the comprehnsive description of coverage, benefits and limitations - which whould be contained in the Combined Evidence of Coverage and Disclsure Form.

If - in the above referenced document - they say that they cover the services of a CNM (Not very many will cover lay-midviwes, I believe) then call ask to be referred to a CNM. Also most insurance companies have not written into their policies that birth must happen with a CNM in a hosptial - but check your policy.

If they do not have any CNM's to refer you to, then ask for a petition so you can petition coverage for your CNM.

It is a lot of work - but worth it.

Also - most hopsital births attended by an OB will cost the insurance carrier about $10,000 or more. Point out to your insurance carrier that the cost of your birth should not exceed $3500.
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#9 of 26 Old 02-20-2002, 08:16 PM
 
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Wow, I am getting concerned about this too. Thanks for all the info. I don't know what kind of ins. we will have when I get prg since dh is job hunting right now.
I have heard somewhere that if the insurance company covers the services of a CNM or even a CN in a hospital, they have to cover the homebirth too. Othewise, they are deciding where she will treat you and that is practicing medicine with out a license. May be worth a try.
Good luck to you all. I will check back and learn from you all
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#10 of 26 Old 02-21-2002, 12:30 AM
 
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I started at the customer service 800 #
I would start there with pacificare and just keep saying this is what I want, how can i get it? Most likely the person you've been dealing with just doesn't know.

You'll probably end up filing an appeal. ask how to do that at customer service.
I know they can be really annoying My mom and dad used to have Pacificare - Had a big fight with them about my dad's injectable MS medications. (which they won)

If you don't have much time I would go straight to the top. Write the president of pacificare cc the letter to everyone else involved If you have complaints about your care to date. Let them know. be direct in the letter telling them what you want and why.

Is there someone (blue sheild calls them a "claims administrator")
that you could talk to?

They are required by law to have an grievance process. here is more info about that at the link below

That's what I know so far. I'm in the middle of it. I will certainly share what I find out.
http://users.aol.com/jasonwolff/hmocntct.htm
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#11 of 26 Old 02-21-2002, 12:40 AM
 
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OOPS Becky N. that one above was for you

Rasjane :

your right! if they cover CNM's they have to cover them everywhere they practice.

That is my juicy tidbit for today! I was told by a blue sheild HMO customer service rep that
"Professional services for maternity care provided by a CNM are a covered benefit." ... "at a hospital, birthing center, or at HOME"

THis came off of her computer screen on their intranet.

So that is what I am going to use for my appeal.

she then went on to tell me that the IPA had to have CNM's in it. so of course I said mine doesn;t which group does? she didn't know. I of course knew there aren't any around that do have CNM's and I told her so. That's when she sugessted the appeal.
She said to include all the reasons why I want a CNM instead of one of their docs. I'm gonna send them a packet all right!
All this is much easier since I'm not pregnant yet, i think
I'm glad I started early.

-Tinyone
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#12 of 26 Old 02-21-2002, 11:16 PM
 
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Thanks, Tinyone!
I called Pacificare today and (after being disconnected several times, transferred about 70 times, and talking to about 12 people who have no brain) I was told that Pacificare (even their VERY expensive PPO) does not cover the services of midwives, CNM or otherwise. Besides, their PPO plan has a 6-mo pre-existing condition waiting period, and pregnancy is a pre-existing condition. We can't really switch companies, either, since we have a business policy thru my husband's business(2 employees- him and I!) P.Care and Kaiser are the only two that will carry companies with less than 10 employees. And we can't get a personal plan b/c my husband has a pre-exising condition that completely disqualifies him (you don't have to qualify medically with business plans).
Anyway, sorry for rambling. Had to vent. It's sooooo frustrating, as you know. I hope you have more luck than I!
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#13 of 26 Old 02-21-2002, 11:45 PM
 
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Becky,
if they told you they don't cover midwives at all, that may be a violation of the law. can anyone help out on this? my understanding is that insurers are required to cover CNM services.

good luck. it's worth it to have a homebirth. i've had two!
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#14 of 26 Old 02-21-2002, 11:54 PM
 
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I believe there is a federal law that now states that health insurance companies cannot consider pregnancy a pre-existing condition.

You should definately look into that.
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#15 of 26 Old 02-22-2002, 12:28 AM
 
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doesn't the law also specify that they can't implement the pre-existing condition clause if you have been covered by another insurance up to the time of the new coverage? the only way they can call anything a pre-existing condition is if you go without coverage for a day before the new coverage begins. i think...
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#16 of 26 Old 02-22-2002, 12:46 AM
 
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Becky,

I know you are in ca but I found this MOST interesting and much like the paragraph I got from blue sheild....

this is from the pacificare in washington
see specifically the page 8 of 24 the 2 and 3d paragraphs.
http://www.opm.gov/insure/99/brochures/73-329.pdf
I bet the ca pacificare plan is the same

there were also some sites that popped up on google.com when I searched for pacificare midwife and pacificare paid midwife. Others have gotten them to pay- I'm looking at it like, if it takes me 10 hrs to get it I've been paid 380.00 an hour as my midwife will cost me 3,800

Tinyone
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#17 of 26 Old 04-17-2002, 04:33 PM
 
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ai yi yi! i've read through this thread of helpful info and my head is spinning. does anyone herein have experience with blue cross? i'm in california and i'm on the ppo share 5k plan. the paperwork says nothing about midwife care for pregnancy/maternity -- doesn't exclude or include it, at least not that i can find. just wanted to know if any of you have experience with this company or plan before i call them cold. no rush -- i'm only a few weeks along! thanks!
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#18 of 26 Old 04-17-2002, 05:36 PM
 
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Word Up,

I myself have Pacificare here in CA- a very lousy HMO plan. I gave up on trying to even get any info out of them for the time being.

HOWEVER- Good news for you- my son has the Blue Cross PPO Prudent Buyer Plan (actually an EPO, which means they only cover the providers on their list- but the selection is excellent)
I was looking throught the provider directory and they have a section for midwives (CNM's only, not direct entry.) There's only one in my area (Riverside, San Bernardino) but I know she does homebirths. So obviously, my son's plan covers midwifery- I see no reason why yours shouldn't if it's a PPO of any kind. Do you have a provider directory or anything like that? Look for the section"midwives." If you know of any midwives near you, you can call and ask them what insurance they take and have good results with. I bet the Blue Cross will work out for you , though. I wish it was my insurance!!! Best of luck to ya!
Becky
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#19 of 26 Old 04-17-2002, 05:47 PM
 
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sadly, no midwives listed in my provider directory -- at least not in my area.
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#20 of 26 Old 04-23-2002, 03:16 PM
 
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You can get insurance to pay for homebirths sometimes !!! We have had 3 children the first was born at the hospital and cost our insurance company ( state ins) over $13,000. and since I was on state insurance I did not have to pay anything. Our sencond pregnancy was very complicated because I switched providers and we still got the insurance to pay for it. I started out going to an OB/ CNM practice and then when I realized that I wasn't going to get what I wanted, I switched at 8.5mo Preggers to a CPM in CT. We were living in RI and it is a sticky quagmire to find out anything about homebirth in RI . We ended up moving to CT to have our dd ( we moved when I was 9mo preg) the rules and regulations in CT are much easier to work with. We had a great birth at home and were very happy whith how everything went.

We moved back to RI when our dd was 6mo and then got preg with #3 when she was 10 mo we decided to stay in RI and had an awesome homebirth.
We didn't think that the first homebirth was going to be covered but afterbecoming a pest to the insurance company and making sure that I held them to their word, they ended up paying for the whole thing we didn't pay a cent. THe insurance for that was UnitedHelathcare
THe second homebirth was great but the insurance was crappy, my dh's employer had switched insurance right before I got preg and we ended up paying alot more for the birth. We would have gotten more from the insurance if we had submitted on time but I had other things to do!!!
I know that pregnancy is not considered a pre-existing condition now so that shouldn't stop an in surance company from covering you. I would definately say that we will always have homebirths, whether our insurance pays for them or we have to It is definately worth it!!!!!!
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#21 of 26 Old 04-24-2002, 06:57 PM
 
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Becky, there is a federal statute prohibiting insurance carriers from not covering insureds for pregnancy; pregnancy can no longer be considered a pre-existing and thus not covered - so if your carrier is telling you this, point out the federal statute and bite them with it:

The HIPPA (aka Health Insurance Portability Act) act of 1996 forbids treating pregnancy as a pre-existing condition. Check this link for specific details on what the Act states:

http://www.auxillium.com/hipaa.shtml

Good luck!
ladybug
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#22 of 26 Old 04-30-2002, 03:26 AM
 
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the only time the health insurance portability act applies is when you are obtaining GROUP health insurance. if you are seeking an individual plan, preexsisting conditions apply and you must qualify health wise to obtain coverage.
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#23 of 26 Old 05-14-2002, 12:05 AM
 
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what the heck kind of insurance company is this??? do they have a office you could go to? That's nuts!
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#24 of 26 Old 05-14-2002, 01:47 AM
 
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I guess it's time for an update on my situation...

My lovely blue shield hmo insurance STILL insists "maternity services provided by a CNM are a covered benefit at clinic... dr office.... hosp or at home"

but the CNM has to be in network. They have none
and they won't let me go out of network to get the benefit!

My out of network request was denied as was my 1 st appeal, I wrote the CEO of blue shield CA today, and I am filing a second appeal and a complaint with the DMHC dept of managed health care,

And I also talked to our risk management dept and my union rep and someone at the nation org of nurse midwives to try to get them to pay, this is all thru a school district so that's it's own buracracy. Some one mentioned maybe I could ask for a "rider" what the heck is that?

This is so stupid it's ridiculous!
So now I think it's time to revise my idea to " If it takes me 100 hours to get them to cover it I've been paid 38.00 an hour"

What next ? my congressman??
I could switch to the PPO but then that would totally screw up my husband's diabetes meds and his dr. care because the whole family must swich at once, and the reimbursement amount for midwives under the ppo is so low it's probably about the same cost to us anyway and then I'd have to risk 20 % of a hospital bill if i had a complication.
so I continue to
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#25 of 26 Old 05-14-2002, 11:20 AM
 
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I used to work for an insurance company - here is a few tips on communicating with them:


Keep a log of your communications - make it VERY detailed!

Who you talked to (First and last name, title, department and direct phone number, as well as the phone number you called to reach them if it was an 800 number or something) You might also ask for their supervisors name and write that down. Do this for EVERYONE they transfer you to as well!!!!!

What was discussed and the outcome of the discussion

The date and time of the conversation

Copies of any faxes or e-mails and receipts or confirmations - be sure these are dated and timed as well.

If you say the word "attorney" in a way which implies that you have one, they are no longer required to talk to you - instead you will have to hire an attorney for them to talk to.

I guarantee you that EVERY phone call you make to them is noted in the system - now all departments may not use the same systems (IE: Pre-auth would have a different system than say disability) but your calls are all there somewhere!!!! BE VERY CLEAR ABOUT WHAT DEPARTMENT YOU ARE SPEAKING WITH!!!

Bear in mind that while most ins companies WANT to provide you with the options ESPECIALLY if they are cheaper, it is like trying to turn a large ship in a rough sea - they just don't turn fast! Be persistant and keep plugging and you WILL get what you want.

If they do not have CNM's on thei provider list then they need to get some! And they are denying you access to appropriate care if they fail to do so, feel free to point that out!

UGH - I could NEVER work for an insurance company again - Just keep calling until you find the person who can help you, if the first person you speak with is uncooperative, hang up and call again and get someone else. Ask to have a nurse case manager assigned to your case to help you - some ins companies will do that - Also - ask for a medical review.
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#26 of 26 Old 05-31-2002, 07:07 PM
 
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gauge14iv great sugestions.

This is a great thread. I am not preg but I am thinking about it. I have always had bad experiences with Insurance Co but now I'm ready for a fight. They better not mess with me... loosers.

Has anyone had any experince with Cigna?
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